Expanding the thoracic donor Pool: Ethical implications of contemporary donor selection and organ preservation strategies.

BACKGROUND: To address high waiting-list mortality and severe donor shortages in thoracic transplantation, clinical protocols have expanded donor selection criteria to include marginal, elderly, and controlled donation after circulatory death (cDCD) candidates. Concurrently, ex-vivo lung perfusion (EVLP), ex-vivo heart perfusion (EVHP), and normothermic regional perfusion (NRP) have reconfigured organ preservation. This study evaluates the clinical-ethical challenges triggered by these strategies to optimize graft utilization safely. METHODS: A systematic review was conducted evaluating peer-reviewed literature (2016-2026) following the PRISMA 2020 statement across PubMed/MEDLINE, Scopus, and Web of Science. Combined search strategies targeting intensive care logistics and thoracic transplantation were employed. Retrieved records were systematically screened at the title, abstract, and full-text levels according to predefined inclusion criteria. Peer-reviewed studies addressing Intensive Care Unit (ICU) donor management, withdrawal of life-sustaining treatment (WLST), and advanced thoracic procurement logistics were qualitatively analyzed. RESULTS: Nineteen studies fulfilled all inclusion criteria. Expanding thoracic donor selection targets relies heavily on precise functional warm ischemia time (fWIT) management and the chronological independence of WLST decisions. While advanced in-situ NRP and ex-vivo EVLP/EVHP preservation techniques maximize cardiothoracic donor assessment and reconditioning, they introduce critical tensions regarding the Dead Donor Rule (DDR) and the definition of circulatory irreversibility. CONCLUSIONS: Safely expanding the thoracic donor pool requires strict operational separation between end-of-life care and procurement teams. Evolving bioethical frameworks serve as analytical safeguards, reinforcing systemic integrity by ensuring advanced preservation technologies respect the donor's bodily integrity and the transition of dying without compromising clinical governance.